


Patient Communication

by 7PercentSolution



Series: You Go To My Head [11]
Category: Sherlock (TV), Sherlock Holmes & Related Fandoms
Genre: Anaesthesia - Freeform, Autistic Sherlock Holmes, Erectile Dysfunction, Established Sherlock Holmes/John Watson, Gen, M/M, Mentions of Cancer, Miscommunication, POV John Watson, So out of his comfort zone, communication deficits, libido, long-term illness and sex, neurosurgeon!Sherlock, neurosurgery
Language: English
Status: Completed
Published: 2018-10-01
Updated: 2018-10-01
Packaged: 2019-07-23 09:44:55
Rating: Not Rated
Warnings: No Archive Warnings Apply
Chapters: 1
Words: 3,800
Publisher: archiveofourown.org
Story URL: https://archiveofourown.org/works/16156529
Author URL: https://archiveofourown.org/users/7PercentSolution/pseuds/7PercentSolution
Summary: When managing his outpatient appointments, Sherlock relies on the communications skills of his trusty Nurse Marie. But, what will he do when a patient wants to speak with him alone, man to man?





	Patient Communication

**_  
_ **

Marie pokes her head around the door. "Mister Andrew Roberts is here."

Sherlock tries hard not to groan in frustration. Follow-up appointments are excruciatingly boring, and he really wishes he could have shoved them all off onto his registrar. Unfortunately, Alice is scrubbing in on another case this afternoon—Grade Four astrocytoma that Lestrade is handling; she hasn't had the opportunity yet to add such a case to her fast growing catalogue of surgical experience while working with Sherlock, so he’d agreed to let her forgo her clinic duties to assist.

There is just enough time for Sherlock to glance down at the file and remind himself of the case before the patient is brought in. Mister Roberts' tumour had been a diffuse, low-grade glioma which Sherlock had removed three weeks ago. No complications arose during the surgery, even though any procedure where the patient is deliberately brought to awareness for a part of the operation is always challenging. Given his communication deficits, Sherlock hates the distraction of having to talk with the patient to be sure that nothing crucial is being affected. He knows that, in theory, the key is to choose a topic of conversation of interest to the patient, but Roberts is an _auto mechanic_. Sherlock doesn’t drive and isn’t interested in cars at all; thank God for the fact that John had agreed to do the anaesthesia for this procedure. Not only is he arguably the best on staff at handling an awake surgery, he’d also stepped in with questions when Sherlock had quickly run out.

"Bring him in," Sherlock prompts Maria, confident now that he has reminded himself of all the pertinent details.

As the thirty-seven-year-old patient comes into the room, Marie remains in the office with them as usual; Sherlock has come to appreciate the fact that her communication skills have spared him from complaints on a regular basis. He doesn’t always pick up on the subtler expressions of the patients, and can be slow to respond to an awkwardly phrased question that takes him time to work out its meaning. Patients rarely have the technical expertise to discuss their own cases with any degree of precision, and their vague and ambiguous expressions and confused questions can make it hard for him. He’s has always found it hard to explain medical things in layman’s terms. And, among the many useful things being with John has taught him there is the fact that miscommunication often takes two: Sherlock recognises his own weaknesses, but also the fact that patients' verbal skills can also be lacking.

As the patient settles into a chair in front of his desk, Sherlock takes a deep breath and mentally reaches for the script that he’s developed over the years.

Eyes still down on the file lying on the desk, he says: "Good afternoon.  As this is the first time we’ve spoken since your discharge, I should reiterate that the MRI conducted fifty-six hours after the operation showed the procedure was successful and the swelling reduced quite quickly during the next few days." He's probably speaking too fast. Is he speaking too fast? Does that make him appear nervous?

He shifts in his seat, forces himself to slow down. "This is good news, Mister Roberts. I suppose the most obvious question now is: how have you been feeling since you were discharged?"

"Um, I suppose as well as can be expected when you're life's effectively over."

Sherlock looks up, startled by the bluntness of the response. For a moment, he is uncertain of how to respond.

Marie steps into the silence. "Oh dear. Has something happened after the surgery to worry you?"

Sherlock checks the file again, just to be sure. The procedure had gone well; the most recent MRI scan results show no residual tumour, which makes him confused.

Tentatively, Sherlock comments: "Your diagnosis of a diffuse low-grade glioma was made four years ago. As I am sure you were told back then, most low-grade gliomas will eventually develop into Stage 3 and 4 malignancy but there is no evidence of that yet. While it is true that many can eventually become fatal, your glioma has been slow growing and only now come to the point where surgical intervention was sensible. Hardly a surprise after the numerous conversations we had during your ward stay, Mister Roberts, and nothing that warrants such melodrama."

Standing behind the patient off to the side, Marie grimaces a little.

 _Ah._ Sherlock now recalls a conversation with her regarding word choices. Apparently, calling patients melodramatic is inadvisable.

"That’s easy for you to say; it isn’t your brain," Roberts replies. "Of course you wouldn't know, because I didn't get any horrible side effects until I went home. The occasional headache, sure, but no  seizures like the one that made me go to the doctor in the first place four years ago.However,  I thought this surgery of yours was supposed to buy me more time; instead, it’s buggered things up royally."

Sherlock is trying to understand the belligerency in the man’s tone of voice. Roberts seems upset, but Sherlock needs more information as to why that might be the case.

He offers, "The MRI results show good results from the surgery; no evidence of anything we missed. Are you saying you have been experiencing unexpected side-effects from the surgery?"

Frowning, the patient looks up at Marie. "Um, could we discuss this in private? If you wouldn’t mind…"

The nurse exchanges glances with Sherlock, her eyebrows canted to ask silently whether he wants her to stay. John has told him often enough that some patients find it easier to talk one-on-one; he’s never really understood why, but if the man wants it, then he’s going to have to make do with whatever Sherlock can manage to say. He nods, even while trying to manage a slight rise in anxiety. This is a good example why he _hates_ communicating with patients; he always seems to end up saying the wrong things.  

After she’s closed the door behind her, Sherlock avoids eye contact with his patient by looking back down at the file. "Right. What do you want to say to me that you felt uncomfortable saying in front of the nurse?"

"Whatever the hell you did when you were digging around in my brain seems to have killed my sex drive."

Whatever Sherlock was expecting to hear, this is certainly not it.

His brows hitch up. "Sex drive… as in your _libido?_ Brain tumours do not generally affect sexual desire, at least not when they are in the location where yours was. I do stress past tense here for a reason. The diseased tissue was removed without impact on any of the neurological systems that support a–– _sex drive_."

It doesn't seem surprising a man fond of cars would use such a term.

Roberts snorts. "None of that doctor stuff you just spouted explains why I want sex but can’t manage it."

Sherlock thinks this one through. "If you are still experiencing sexual _desire_ then it suggests your neural mechanisms in different areas of your brain that create libido are still functioning. _"_

"Yeah, that’s the problem in a nutshell. I _want_ sex just the same as always. Only I can’t do it, now. Did the knife slip or something? Because I sure can’t do what I’ve always been able to do before now."

Defensively, Sherlock retorts: "Whatever you imagine happens in brain surgery, Mister Roberts, this is not the Middle Ages; our instruments are much more refined than _knives_. As you know, we did a full preoperative functional neuroimaging and during the operation you were kept awake so that we could conduct electrical cortical mapping and make sure that none of your key functions were affected. We were very careful to map both horizontal cortico-cortical connectivity as well as vertical cortico-subcortical connectivity with the aim to preserve the networks underlying the minimal common core of your brain. "

"Christ, did you just swallow a dictionary or something? I’m telling you I can’t get it up anymore and you spout that stuff? Just tell me the truth! Am I always going to be like this, now?"

"If you are talking about sexual _arousal_ rather than desire, are you saying that you’ve been experiencing erectile dysfunction since the surgery?"

" _Yes!_ How much clearer do I need to be?! I can’t get it up, and I can’t get off! And without that, my wife doesn’t get what she wants either. We’re royally screwed because we can’t fuck. Is that plain enough for you?"

Stung by the shouting, Sherlock retreats into process. "How often has this occurred?"

"Each and every time we’ve tried to make love since I got home from the hospital."

Sherlock’s brows crinkle in confusion. "You must have been provided with the after-care leaflet that advises you to avoid physical exertion in the immediate aftermath of discharge. Raising the intracranial pressure so soon after surgery is not advisable."

"Yeah, I know. I read your bloody leaflet, so we didn’t even try for the first three nights. As soon as I felt well enough to stop taking the painkillers and those steroid tablets, we tried. And _failed._ It freaked me out so much that when Sharon went off to work I tried again, and I couldn’t even beat off. I want to know why. I’m not an idiot. I’d remember if you’d told me about this possible side effect when I signed the consent form. And I sure as hell wouldn’t have signed if there was the remotest chance of losing my cock in the process." Roberts crosses his arms and shoots a defiant stare.

Sherlock hears the hostility and the accusation in the patient’s tone of voice. "No amputation of genitalia was involved, Mister Roberts. If you entered the OR with a penis, I am sure you left it with one. Although it may sound like a cliché, it’s early days yet. Have you considered the fact that the psychological effects of the surgery may be the cause of your current dysfunction?"

"Oh, so now you’re going to try to pin the blame on me, are you? Well, I’ll have you know, my cock is a well-oiled machine, and it’s never, ever let me down, even though I’ve been living with this diagnosis for years. Until now. Until you messed up my operation. So, if anyone’s to blame, it’s _you._ "

"No need for blame to be laid anywhere by anyone. However, your glioma had advanced from the monitoring stage to the surgical, and this might be causing you worry at a subconscious level. Psychological distress associated with the diagnosis and the surgery could also have led to a change in your wife’s attitudes toward your relationship; such difficulties are documented in literature. No single area of the brain controls sexual function; in fact, a lot of it happens outside of the brain, in the spinal cord. From a physiological perspective, sexual arousal is controlled by the parasympathetic portion of the autonomic nervous system and manifests itself as vasodilation in sexual organs along with several other physiological phenomena including an increase in heart rate. Orgasms and male ejaculation are, however, controlled by the sympathetic portion––"

Roberts interrupts: "I don’t know what the hell all that means. I just know that something _you_ did means that me and the missus can't enjoy ourselves every day the way we used to."

" _Every_ day?" Sherlock is probably showing his surprise, but he is genuinely startled by the revelation. John and he have such a busy and stressful life that even once a week is sometimes hard to manage. The average married couple in Britain makes love less than once a week, and at the age of Mister Andrews, that can drop even lower.

"Yes. For the past eleven years we’ve been married. It's always been good, we've been like clockwork, and now the clock has stopped. And that means our relationship is going to go to hell in a hand-basket. It’s only a matter of time before she starts looking elsewhere. Christ, it’s like I’m already in the grave, and she’s surely going to start looking for another lover."

"Mister Andrews, I am not a urologist or an endocrinologist, either of whom would be better qualified to deal with issues of sexual dysfunction. But, I do know it has been only three weeks since your brain surgery and recovery is not instantaneous. Not the physical side, nor the psychological one, either. Have you been depressed since the operation?"

"Depressed? Hell, yes. You’d be depressed if you thought you’d never have sex again; any man would. I don’t think it’s psychological. I knew all about the tumour before the operation, and so did Sharon. We made love the night before, no problem. Christ, I even had an erection when that cute blonde anaesthetist was working on me just before the operation."

One of the new anaesthesia registrars had been assisting John with preparations. Objectively speaking she has long, blonde hair, a propensity to smile, she's young, has sizable breasts, and is in the low end of the normal weight range. All attributes which the average heterosexual male might pay attention to particularly when combined.

Sherlock waves a dismissive hand. "Loss of inhibitions is a common side-effect of propofol, nothing surprising there."

"What is surprising is the total lack of anything down there ever since you did the surgery. Not even morning wood, or a wet dream. So, unless you mucked something up, I should be in good working order."

Sherlock is beginning to feel very uncomfortable and anxious, since the conversation seems to be going around in a circle. The patient reiterates his stance that something is wrong, but every attempt to provide factual scientific information to reassure him is falling on deaf ears. Sherlock doesn’t seem able to explain the situation to this patient in a way that is easing the man’s aggravation. If anything, he seems more riled up and angry than he was when he entered the consulting room.

He retreats into the script. "I need to ask you a number of questions regarding your physical recovery."

Roberts rolls his eyes. "Ask away."

"How long was it before your post-operative headache eased? Have you had any since?"

"I felt much better by the weekend after I left here. Only had a couple of what you could call normal headaches since; nothing that paracetamol couldn’t handle."

"Any nausea, vomiting or dizzy spells?"

"No."

"What about involuntary muscle jerking, tingling, numbness in any part of your body? Any buzzing in your ears?"

"No. Is this your version of playing twenty questions? I tell you, I’m feeling fine, and ready to go back to work next week; shame my cock doesn’t feel the same."

"Have you had any weakness in a part of your face or on one side of your body?"

"No. Apart from my lack of stiffies there’s no weakness anywhere."

"Any difficulties in walking or balance?"

"No."

"I recall in our discussion before the surgery that we discussed how as the glioma develops you may experience small seizures that you barely notice, resulting in unusual smells, funny feelings in your stomach or brief spells that you can’t explain. Any of those?"

"No."

"Any short-term memory issues?"

"I can still remember that I came to you to complain about what’s happened to my sex life, but you prefer to ignore that."

Sherlock decides this is sarcasm, and decides against addressing it. Marie says it's often intended to be rhetorical. "What about your sense of smell? Or vision?"

"None of the above. And I can hear just fine, too. What I’m not hearing is an answer."

"Please allow me to continue with the post-surgical follow-up protocols."

Roberts's mouth tightens into a line. "Whatever."

"Any changes in personality?"

"Yeah. My wife’s horny and I can’t do anything about it."

"I guess that means you do tick the box for being irritable."

"Damn right. Before we go any further down this route of making me sound like some sort of nut job, you should know that I cared just as much about sex before the op as now. I haven’t lost interest or been depressed. I’m _angry_." Roberts points a finger at Sherlock’s left hand. "You’re wearing a ring, so you’re married. How would you feel if you’d just lost your ability to ever have sex again with your wife?"

"I don’t have a wife; I have a male partner––a _fiancé_ , I mean," Sherlock stammers.

Mister Roberts shakes his head. "Just what I needed to hear. You’re one of those people, so not even interested in how it works between a normal bloke and his wife. Well, just my luck to get you as my surgeon. Where do I file a complaint?"

Sherlock stiffens. "That is your right, of course, if that's how you feel. I could ask Nurse Marie back in so that she can direct you to the Patients Advice and Liaison Service here at Kings."

As much as he’d be glad to see the back of this patient, almost as if he can hear a little sigh from John, Sherlock hesitates. He doesn’t want to leave yet another one of what John calls his messes to him and Lestrade. He has very little to lose, if Mister Roberts is already unhappy enough to consider a formal complaint.

So, he draws a deep breath and launches in: "Before you aggravate your mood even further by engaging with bureaucracy, I’m going to suggest something that you may not want to hear. For the past four years since your diagnosis, it would seem that you have preferred not to think about it."

Roberts snaps: "I didn’t want to, and I didn't have to; the symptoms weren’t bad enough, but now thanks to you, they are."

"As I have already said, there is no physiological reason to assume that the surgery is implicated in your current ‘loss of form’, as one might put it. Mister Roberts, I don’t often refer to my own private life when talking to patients, but you might find this enlightening, so I’m going to make an exception. Whatever you may think about my sexual orientation, I can assure you that my partner  and I have a loving relationship. Some time ago, he suffered a severe injury while on tour in Afghanistan and was angry and upset for months. What was worse for him is that his physical recovery took much less time than regaining his mental equilibrium did, which affected our sex life. What I discovered during that time was that time is needed to heal, but only if you both make an effort to address the issues that really caused the problem."

Roberts makes a face. "Too much information here. What does any of that have to do with me?"

"Your glioma is not currently life-threatening. But it will be. That is inevitable. The surgery has made your impending mortality more evident and it is upsetting you, even if you don’t want to admit it. The surgery made the issue very concrete and inescapable. Perhaps, what you need is a moment to re-consider how you spend the years remaining. It’s not a question of quantity, but of quality. Instead of demanding to be in perfect health until the day you die, perhaps it would help both you and your wife to consider making the best of whatever situation in which you find yourselves. You are more than an erect penis, and your wife is more than a vagina that needs stimulation. While difficulties in having it may serve as an indicator of problems, your marriage is more than sex. The bonding of intimacy does not need erectile penetration, and one’s love is not measured in the volume or frequency of ejaculation. Perhaps if you relax, and apply less pressure to yourselves, you both will be able to enjoy sexual contact again."

For Sherlock, it’s a very long speech, but there is still one more thing he wants to add. It may have absolutely no effect on Mister Roberts, but it seems necessary all the same, so he adds: "On your way out, book an appointment for a month’s time and we will discuss this further. If there is no progress, then you can file that complaint, and I can make a referral to our urology services. Neither is likely to resolve the problem. In the meantime, do yourself a favour. Stop trying to repeat your past performances; find other ways to be intimate. Your motto should be _that was then, this is now_. See if it makes a difference."

oOoOoOoOo

**Three Weeks Later**

Marie is going through the list of upcoming appointments. This time, Alice is sitting alongside Sherlock in the consulting room as they divide up the sessions. Sherlock is keen to pass on as much of the clinic hours as he can to her; not only is she happy to do them, it also suits Sherlock because he knows she is better at patient communication than he is.

It’s been what John would call an utterly shite day; a major procedure Sherlock had been looking forward to all week was cancelled because the patient had stroked out at home. He’s had his fill of paper-work to do, and John’s away at the Association of Anaesthetists of Great Britain and Ireland Congress in Dublin. Sherlock’s level of grumpiness has risen for every hour that they are apart, but he’s trying hard not to take it out on his colleagues. It’s not their fault that John has to attend this thing; he is delivering a paper Sherlock had encouraged him to write about increasing OR cost-effectiveness by developing a novel system of allocating surgical hours to different specialties.

Marie is teasing his registrar: "Don’t let him dodge all of his duties, Alice; not fair. Now, about Mister Andrew Roberts. He booked in for the last appointment on Thursday; I was surprised when he asked for another one so soon, because he wasn't due for his next one until at ten weeks, after the next MRI."

Sherlock’s face must have betrayed his feelings because Alice interjects: "I can take the appointment if you’d like."

Shaking his head, Sherlock says: "He won’t want to talk to a female doctor; he chased Marie out of the room when he last saw me. Probably going to file a complaint against me, anyway."

"Oh dear…."Alice’s eyes widen. "What happened?"

Marie raises a hand. "Relax, both of you. He called this morning to cancel that appointment. He didn't really explain why, just said: ' _tell the doc that his advice worked; that was then, this is now’_. He said you’d understand."

Sherlock smiles for the first time today.

 


End file.
